What thickeners can be used for a 2-month-old infant with gastroesophageal reflux disease (GERD)?

Thickeners for 2-Month-Old Infants with Reflux

For a 2-month-old infant with reflux, rice cereal (1 tablespoon per ounce of formula) is the recommended thickener, but should be avoided in preterm infants due to risk of necrotizing enterocolitis. 1

Types of Thickeners Available

Different thickening agents can be used for infants with gastroesophageal reflux:

• Rice cereal: Most commonly used thickener in formula-fed infants

  • Dosage: 1 tablespoon per ounce of formula (increases caloric density to 34 kcal/oz) 1
  • Effectively reduces regurgitation episodes 2
  • CAUTION: Not recommended for preterm infants (<37 weeks) due to risk of necrotizing enterocolitis 1

• Commercial anti-regurgitant formulas:

  • Contain processed rice, corn, or potato starch 1
  • Preferred over adding thickeners to standard formulas due to better viscosity, digestibility, and nutritional balance 2

• Other thickening agents (though rice cereal is most common in clinical practice):

  • Corn starch
  • Carob bean gum
  • Soy bean polysaccharides 2

Effectiveness of Thickeners

Thickened feeds have demonstrated several benefits:

• Reduce frequency and severity of regurgitation 2, 3
• Moderately effective in treating gastroesophageal reflux 4
• Increase weight gain 2
• May improve reflux-associated symptoms 2
• Reduce the duration of the longest reflux episode 4

Evidence shows that infants on thickened formulas experience nearly two fewer episodes of regurgitation per day compared to those on unthickened feeds 3.

Approach to Management

1. First, determine if intervention is needed:

   • Normal physiologic gastroesophageal reflux occurs in approximately 50% of infants daily 1
   • Most regurgitation resolves by 12 months of age without treatment 5

2. For formula-fed infants with persistent symptoms:

   • Start with rice cereal thickening (1 tablespoon per ounce) 1
   • Consider commercially available pre-thickened anti-regurgitant formulas 1, 2

3. For breastfed infants:

   • Consider a 2-4 week maternal elimination diet that restricts at least milk and egg 6, 1
   • Thickening expressed breast milk is more challenging but can be considered

4. Additional supportive measures:

   • Reduce feeding volume while increasing feeding frequency 6
   • Hold infant upright for 20-30 minutes after feeding 1
   • Keep the infant's head elevated when awake 1

Important Cautions and Monitoring

• Monitor for constipation, which can occur with rice cereal thickening 1
• Track weight gain and growth to ensure adequate nutrition 1
• Avoid thickeners in preterm infants (<37 weeks) due to risk of necrotizing enterocolitis 1
• Recognize when to refer: If symptoms persist despite thickened feeds and conservative measures, consider referral to pediatric gastroenterology 1

Common Pitfalls to Avoid

• Mistaking normal physiologic GER for pathologic GERD requiring medication 1
• Failing to recognize cow's milk protein allergy, which can mimic or coexist with GERD 1
• Relying solely on thickening without implementing other measures like positioning and feeding modifications 1
• Overusing acid suppressants without confirmed GERD diagnosis 1

Remember that while thickeners are effective for managing reflux symptoms, they should be part of a comprehensive approach that includes proper feeding techniques and positioning strategies.